Resident #118 was hospitalized December 30 with acute encephalopathy after a drug screen revealed trazodone in his system — a medication he was never prescribed, according to federal inspection records from Optalis Health and Rehabilitation of Grand Rapids. The same drug screen showed no traces of alprazolam, the anxiety medication he was supposed to receive.
Hospital physicians noted the resident "was difficult to arouse in the emergency department" and required intensive care monitoring. One hospital note stated the altered mental status "may have been related to trazodone found on a drug screen, there is no documentation of this ever being given at the facility."
The medication error occurred amid what staff described as dangerous understaffing that left residents without nurses for entire shifts. On October 18, no nurse was assigned to the 300 Hall from 6:30 PM to 11:00 PM, leaving approximately 50 residents without medication administration or nursing care.
Licensed Practical Nurse QQ worked that evening and reported: "The Agency nurse scheduled to relieve them at 6:30 PM on the 300 Hall did not show up for the shift." She said no residents on the 300 Hall received scheduled medications that evening.
The staffing crisis created a cascade of missed medications for residents with serious conditions. Resident #103, who has a seizure disorder, missed his evening dose of levetiracetam on October 18. Medical literature states that missing seizure medication "is the most common cause of breakthrough seizures" and can lead to status epilepticus, a potentially fatal condition.
Resident #113 missed her insulin injection on October 12, while Resident #125 missed multiple insulin doses on October 18 and 19. Both residents have diabetes and require insulin to manage their blood sugar levels.
Resident #124, who has atrial fibrillation and a history of pulmonary embolism, missed doses of Eliquis, an anticoagulant that prevents blood clots. Missing anticoagulant doses can increase the risk of strokes and heart attacks.
Agency Licensed Practical Nurse JJJ described the chaos: "That evening there was no nurse assigned to the 300 Hall between 6:30 PM-11:00 PM. There was only a nurse on the 400 Hall." She said this wasn't the first time entire sections went without nurses, adding: "I canceled all my shifts after that. Did not feel safe working there."
The staffing problems intensified after the facility changed ownership in September 2024. Licensed Practical Nurse QQ said: "After the change in ownership, only two nurses were scheduled on the 300/400 Halls, when previously they had three, and stated that is how we ended up with this mess."
Staff described working conditions that compromised patient safety. Licensed Practical Nurse OOO reported being assigned over 50 residents alone one night. "They were telling me I had to work like that. I told them there are people who are a fall risk, people with mental health issues. I told them it's not safe. I am not going to put these people's lives in jeopardy."
That same evening, the keys to medication carts were locked inside, preventing access to residents' medications. "I never got report or nothing about that hall or any of those patients," LPN OOO said.
The understaffing created a domino effect of care failures. During the October 18 incident, Resident #103 attempted to elope from the facility and was found in the parking lot after triggering a door alarm. Certified Nursing Assistant RRR, who was assigned to him, was caring for another resident when he wandered off.
"There was a nurse on the 400 Hall, but when they asked the 400 Hall nurse for assistance they would say they were busy," according to inspection records. CNA RRR said: "I was like, then who should I ask?"
Residents and families reported the impact of inadequate staffing on basic care. Resident #101, who is cognitively intact, said she waited up to an hour for incontinence care after bowel movements and went almost two weeks between bed baths. She said staff seemed rushed: "You get the feeling that they are in a hurry, so she did not ask for help to wash her hair."
Bath records showed Resident #101 received only five showers or baths over a 30-day period, with three documented refusals that had no supporting documentation or follow-up.
Resident #107 reported waiting up to two hours for brief changes after bowel movements, while Family Member VV said Resident #104 "just smells of urine" due to inadequate hygiene care.
The facility's reliance on agency staff created additional problems. Licensed Practical Nurse Q said: "With Agency staff, the nurses working have no notification when a scheduled Agency staff member calls in or cancels a shift, and stated we have no idea if they will show up or not."
Agency Licensed Practical Nurse DDD explained the time pressures: "When only two nurses are on the 300/400 Hall it gets very time sensitive regarding care. Staffing constraints result in medications/treatments being administered outside of designated time frames."
On the memory care unit called The Harbor, Certified Nursing Assistant R reported that many residents required staff assistance with feeding, but there were typically only three aides available. "Sometimes there was only 2 aides and a nurse on the unit which was not enough because they couldn't keep an eye on every resident adequately."
Certified Nursing Assistant X described days when there wasn't enough staff to feed dependent residents their meals. "The facility hadn't had enough staff to feed dependent residents for lunch and dinner the day before. At times, there had not been enough staff to feed residents for breakfast either."
The medication error involving Resident #118 revealed additional safety concerns. Facility records showed controlled substances were pulled from his medication supply on dates when no valid physician order existed. Three doses of alprazolam were removed from inventory, but only one administration was documented in his medication record.
Assistant Director of Nursing C acknowledged that the drug screen showed "no alprazolam in his system, which he did have a prescription for and per the facility medication administration records had been given two doses prior to his hospitalization."
The resident had also been prescribed amiodarone, a heart medication that cannot be safely combined with trazodone due to dangerous drug interactions.
Registered Nurse LLL, who worked the facility briefly, said staffing was "definitely an issue that night" and cited safety concerns as a reason for leaving: "That was one of the reasons I left, safety."
Director of Nursing B and Assistant Director of Nursing C acknowledged the facility "recognized an issue related to the 300 Hall and missed medications on 10/18/24" but provided limited details about corrective actions.
Former Assistant Director of Nursing MMM, who was responsible during many of the incidents, reportedly "often did not answer the phone" when staff called with concerns at night and "wouldn't come in and get on a cart or help at all," according to Licensed Practical Nurse OOO.
The inspection found that residents throughout the facility were affected by the administrative failures, with 92 residents potentially impacted by the inability to maintain adequate staffing levels and ensure proper medication administration.
Resident #126, who has diabetes and anxiety, recalled several nights in October when no nurse was assigned to her hall. "I guess the nurse just didn't show up. I think that is what the excuse was." She worried about missing her diabetes medications: "I was kind of worried because I didn't know. I have sugar. I didn't know then if I would have a reaction."
The anxiety from the uncertain care became overwhelming for her: "The anxiety got to be so bad, nobody handing out meds, there was no one."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Optalis Health and Rehabilitation of Grand Rapids from 2025-01-14 including all violations, facility responses, and corrective action plans.
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